•
The reviewer must consult with a qualied health professional (and others as needed) when
the denial is based on a determination of whether a particular treatment, drug or other item is
experimental, investigational, or not “medically necessary”;
•
Plans can require no more than two levels of review; and
•
Mandatory binding arbitration of claims is generally prohibited. However, non-binding arbitration
is permissible if done within the required timelines.
For more information on disability claims and appeals, request a copy of the publication An
Employer’s Guide to Health and Disability Benefit Claims
. See “Resources” in the back of this
booklet for information on obtaining copies.
Plans not grandfathered under the Affordable Care Act (those established, or that have made certain
signicant changes, after March 23, 2010) must comply with additional internal claims procedure
requirements. The claims and appeal process must cover rescissions (retroactive cancellations) of
coverage, as well as other denials of benets. They, or their insurers, also must:
•
Provide claimants with new or additional evidence or rationale, and a reasonable opportunity to
respond to it, before making a nal decision on the claim;
•
Ensure that claims and appeals are adjudicated in an independent and impartial manner;
•
Provide detail in all claims denial notices on the claim involved, the reason for denial (including
the denial code and meaning), any available internal and external appeals processes, and
consumer assistance information;
•
Provide, on request, diagnosis and treatment codes (and their meanings) for any denied claim;
•
Provide notices in a culturally and linguistically appropriate manner;
•
Allow claimants to begin the external review process if the plan fails to follow the internal claims
requirements (unless the plan’s violation is minimal); and
•
Allow claimants to resubmit a claim through the internal claims process if a request for
immediate external review is rejected by the external reviewer under specic circumstances.
In addition, plans not grandfathered under the Affordable Care Act must provide for external review of
claim denials by an independent party. Plans that are grandfathered must also provide external review
if the claims are within the protections of the No Surprises Act (discussed below). The external review
process used by the plan depends on whether the plan is self-funded or provides benets through an
insurance company.
Self-funded plans generally must comply with the procedures set by the Department of Labor. A plan
may choose to refer requests for external review to an accredited Independent Review Organization,
or may voluntarily comply with a state external review process if the state allows access. For more
information, visit the Department of Labor’s web page on internal claims and appeals and
external review
.
Insured plans and insurance companies generally must comply with their state’s external review
process, if the state process includes minimum consumer standards set by the Department of Health
and Human Services (HHS). If the state process does not meet these standards, group health plans
and insurers may use either the accredited Independent Review Organization process or an HHS-
administered Federal external review process. For the status of your state’s external process, see
HHS’s website
.
UNITED STATES DEPARTMENT OF LABOR
8